Pennsylvania Licensed Physician Advisor

Job Summary

Providing clinical expertise and guidance, the full-time Pennsylvania Licensed Physician Advisor will support the Clinical Analysis and appeals team by managing medical necessity appeals and PAMA utilization reviews in a remote capacity.

Key responsibilities

• Act as the physician advisor for medical necessity appeals and PAMA utilization reviews
• Serve as a resource for regulatory and revenue cycle denial and appeals processes related to hospital activities
• Utilize strong knowledge of the Interqual Criteria Set and hospital reimbursement systems to guide clinical decisions

Required qualifications

• Doctorate Degree in Medicine or Osteopathic Medicine
• PA Medical Physician License or PA Osteopathic Physician License
• Strong working knowledge of the Interqual Criteria Set and hospital reimbursement systems
• Experience with Second and Third level appeals processes, including expert witness experience
• Experience in a managed care environment